Opioid-related Hospitalizations Research Articles

Opioid Dose and Benzodiazepine Use Among Commercially Insured Individuals on Chronic Opioid Therapy.

To examine morphine milligram equivalent (MME) trends, use of concurrent opioids and benzodiazepines, and opioid-related emergency department (ED) visits or hospitalizations in a national cohort of patients on chronic opioid therapy. Retrospective cohort analysis of prospectively collected data from the Truven Health MarketScan Commercial Claims and Encounters database from 2009 to 2015. This includes individuals in both the Commercial Claims and Medicare Supplemental databases of MarketScan. MME comparisons of 1) patients on chronic opioids with and without opioid-related ED visits or hospitalizations, 2) patients on concurrent opioids and benzodiazepines with and without opioid-related ED visits or hospitalizations, and 3) patients on chronic opioids compared with those on concurrent opioid and benzodiazepine using the Student t test. MME decreased from 194 mg in 2009 to 119 mg in 2015 among patients on chronic opioids. Patients on opioids and benzodiazepines had higher doses than those on opioids alone for all years (P < 0.001). Those with an opioid-related ED visit or hospitalization had a higher average MME than those without, for all years except 2009 (P < 0.05). Patients on chronic opioids or on concurrent benzodiazepine with an MME >50 had a twofold increased risk of having an opioid-related ED visit or hospitalization compared with those with an MME <50, for all years. Although the average MME decreased over time, patients on combination opioid and benzodiazepine and those with opioid-related ED visits and hospitalizations had significantly higher doses.

Opioid-Related Hospitalization and Its Association With Chronic Diseases: Findings From the National Inpatient Sample, 2011-2015.

Chronic disease and opioid-related hospitalizations in the United States are increasing. We analyzed nationally representative data on patients aged 18 years or older from the 2011–2015 National Inpatient Sample to assess the association between opioid-related hospitalization and chronic diseases. We found that most patients with opioid-related hospitalization were white, aged 35–54 years, in urban hospitals, and had 2 or more comorbid conditions. Patients with 2 or more chronic conditions accounted for more than 90% of opioid-related hospitalizations in all years. The results suggest a need for targeted interventions to prevent opioid misuse in patients with multiple chronic conditions.

Opioid Epidemic or Pain Crisis? Using the Virginia All Payer Claims Database to Describe Opioid Medication Prescribing Patterns and Potential Harms for Patients With Cancer.

A key challenge regarding the current opioid epidemic is understanding how concerns regarding opioid-related harms affect access to pain management, an essential element of cancer care. In certain regions of the United States where disproportionately high cancer mortality and opioid fatality rates coexist (such as southwest Virginia in central Appalachia), this dilemma is particularly pronounced. This longitudinal, exploratory, secondary analysis used the Commonwealth of Virginia All Payer Claims Database to describe prescription opioid medication (POM) prescribing patterns and potential harms for adult patients with cancer living in rural southwest Virginia between 2011 and 2015. Descriptive and inferential statistical analyses were conducted at the patient, prescriber, and prescription levels to identify patterns and predictors of POM prescribing and potential harms. To explore geographic patterns, choropleth and heat maps were created. Of the total sample of patients with cancer (n = 4,324), less than 25% were prescribed a Controlled Substance Schedule II POM at least three times in any study year. More than 60% of patients never received a Controlled Substance Schedule II POM prescription. Six hundred fifty-two patients (15.1%) experienced 1,599 hospitalizations for any reason; 10 or fewer patients were admitted for 11 opioid use disorder-related hospitalizations. The main findings suggest potential undertreatment of cancer-related pain; no difference in risk for opioid-related hospitalization on the basis of frequency of POM prescriptions; and geographic disparities where opioid overdoses are occurring versus where POM prescription use is highest. These findings have significant opioid policy and practice implications related to the need for cancer-specific prescribing guidelines, how to optimally allocate health delivery services, and the urgent need to improve data interoperability and access related to POMs.

Association between homelessness and opioid overdose and opioid-related hospital admissions/emergency department visits

BackgroundAlthough homelessness and opioid overdose are major public health issues in the U.S., evidence is limited as to whether homelessness is associated with an increased risk of opioid overdose. ObjectiveTo compare opioid-related outcomes between homeless versus housed individuals in low-income communities. Design, Setting, and ParticipantsCross-sectional analysis of individuals who had at least one ED visit or hospitalization in four states (Florida, Maryland, Massachusetts, and New York) in 2014. MeasurementsRisk of opioid overdose and opioid-related ED visits/hospital admissions were compared between homeless versus low-income housed individuals, adjusting for patient characteristics and hospital-specific fixed effects (effectively comparing homeless versus low-income housed individuals treated at the same hospital). We also examined whether risk of opioid-related outcomes varied by patients' sex and race/ethnicity. ResultsA total of 96,099 homeless and 2,869,230 low-income housed individuals were analyzed. Homeless individuals had significantly higher risk of opioid overdose (adjusted risk, 1.8% for homeless vs. 0.3% for low-income housed individuals; adjusted risk difference [aRD], +1.5%; 95%CI, +1.0% to +2.0%; p < 0.001) and opioid-related ED visit/hospital admission (10.4% vs. 1.5%; aRD, +8.9%; 95%CI, +7.2% to +10.6%; p < 0.001) compared to low-income housed individuals. Non-Hispanic White females had the highest risk among the homeless population, whereas non-Hispanic White males had the highest risk among the low-income housed population. LimitationsIndividuals with no ED visit or hospitalization in 2014 were not included. ConclusionHomeless individuals had disproportionately higher adjusted risk of opioid-related outcomes compared to low-income housed individuals treated at the same hospital. Among homeless individuals, non-Hispanic White females incurred the highest risk. These findings highlight the importance of recognizing the homeless population—especially the non-Hispanic White female homeless population—as a high-risk population for opioid overdose.

Opioid Prescribing After Opioid-related Inpatient Hospitalizations by Diagnosis: A Cohort Study.

Any opioid-related hospitalization is an indicator of opioid-related harm and should ideally trigger carefully monitored decreases in opioid prescribing after inpatient stays in many, if not most, cases. However, past studies on opioid prescribing after hospitalizations have largely been limited to overdose related visits. It is unclear whether prescribing is different for other opioid-related indications such as opioid dependence and abuse and how that may compare with hospitalizations for overdose. To examine opioid-prescribing patterns before and after opioid-related hospitalizations for all opioid-related indications, not limited to overdose. Retrospective cohort analysis of Veterans Health Administration (VHA) administrative claims from 2011 to 2014. VHA patients who were hospitalized between fiscal years 2011 and 2014 and had at least 1 prescription opioid medication filled through the VHA pharmacy before their hospitalization. Opioid dispensing trajectories after hospitalization by opioid-related indication (ie, opioid dependence and/or abuse vs. overdose) compared with prescribing patterns for non-opioid-related hospitalizations. Overall, opioid dosage dropped significantly (66% for dependence/abuse, 42% for overdose, and 3% for nonopioid diagnoses; P<0.001) across all 3 categories when comparing dose 57-63 days after admission to 57-63 days before hospitalization. However, 47% of the patients remained on the same dose or increased their opioid dose at 60 days after an opioid-related hospitalization. After adjusting for covariates, patients with a primary diagnosis of dependence/abuse had higher odds of having their dose discontinued compared with those with overdose: odds ratio (OR) 2.17 (1.19-3.96). Patients with admissions for opioid dependence and/or abuse had a statistically significant higher prevalence of depression, posttraumatic stress disorder, anxiety, and substance use disorders compared with those with an opioid overdose hospitalization. Opioid prescribing and patient risk factors before and after opioid-related hospitalizations vary by indication for hospitalization. To reduce costs and morbidity associated with opioid-related hospitalizations, opioid deintensification efforts need to be tailored to indication for hospitalization.

261 Identifying Barriers to Emergency Department-Initiated Buprenorphine: A Spatial Analysis of Treatment Program Access in Michigan

Emergency department (ED)-initiated medication-assisted treatment (MAT) with buprenorphine/naloxone has been shown to improve treatment retention and reduce illicit opioid use, however, its potential may be limited by a lack of accessible community-based programs. This study compared one state’s geographic distribution of EDs to outpatient treatment facilities that prescribe buprenorphine, and identified emergency department and county-level factors associated with buprenorphine program access. Treatment facility data was obtained from the SAMHSA 2018 National Directory of Drug and Alcohol Abuse Treatment Facilities, and Michigan emergency department data was obtained from the state chapter of the American College of Emergency Physician’s 2018 ED directory. Opioid prescribing, opioid overdose, and opioid-related hospitalization statistics were obtained from the Michigan Department of Health and Human Services (DHHS) 2017 data set. Sociodemographic data were acquired from the U.S. Census Bureau. Geospatial analysis compared EDs to buprenorphine treatment facilities using 5 and 10 mile radii. Among 131 non-exclusively pediatric emergency departments in Michigan, 57 (43.5%) had a buprenorphine-prescribing treatment facility within 5 miles, and 66 (50.4%) had a facility within 10 miles; of the latter, 61 (92.4%) took Medicaid, and 59 of 61 (96.7%) offered outpatient services. EDs within 10 miles of a Medicaid-accepting, outpatient buprenorphine treatment facility had higher average numbers of beds (41 vs. 15; p<0.0001) and annual patient volumes (58,616 vs. 17,484; p<0.0001) compared to those without. Of Michigan’s 83 counties, 72 (86.7%) were reported to have at least one ED in 2018; 27 (37.5%) of these were in counties with buprenorphine treatment programs. Compared to ED-containing counties with buprenorphine treatment facilities, those counties without such services were more likely to have smaller average populations (82,910 vs. 221,094; p=0.04) and higher proportions of residents with low educational attainment (10.9% vs. 9.0%; p<0.01), but similar proportions of residents with low income (16.8% vs. 16.2%; p=0.56) and unemployment (4.7% vs. 4.9%; p=0.61). ED-containing counties without and with buprenorphine programs had similar rates of opioid prescribing (1.08 vs. 1.01; p=0.21), opioid-related hospitalizations (19.0 vs. 20.8 per 100,000; p=0.53), and opioid overdose deaths (13.5 vs. 17.5 per 100,000; p=0.08). Only half of Michigan’s emergency departments are within 10 miles of an outpatient buprenorphine-prescribing treatment facility, despite similar rates of opioid-related morbidity statewide. Given both the limited access of EDs to buprenorphine treatment facilities (especially in less populous areas), and the ongoing opioid overdose crisis, expanding ED-initiated MAT in states similar to Michigan may require alternative models of care.

The Associations of Neighborhood Availability of Marijuana Dispensaries and DATA-2000 Waivered Providers with Hospital Stays Related to Opioids

Background: Evidence is emerging on how state-wide marijuana legalization and increased supply of DATA-2000 waivered providers may be associated with outcomes related to opioids. It is unknown whether such associations remain at the neighborhood level. Objectives: This study examined the associations of neighborhood availability of marijuana dispensaries and DATA-2000 waivered providers with opioid-related hospital stays. Methods: Discharge-level records of inpatient (N = 264,013) and observation stays (N = 12,621) were obtained from the Washington Comprehensive Hospital Reporting System from January through June 2016. Outcomes were indicators for inpatient stays related to opioid use disorder (OUD), inpatient stays related to opioid overdose, and observation stays related to OUD. Primary predictors were the density of marijuana dispensaries and DATA-2000 waivered providers at the zip code level. Multilevel logistic regressions with random intercepts were used to examine the cross-sectional associations, controlling for other patient and neighborhood characteristics. Results: Patients living in neighborhoods with one more recreational marijuana dispensaries per square mile were more likely (OR = 1.54, p = .017) to be diagnosed with OUD in inpatient stays. Living in neighborhoods with increased density of medical marijuana dispensaries or DATA-2000 waivered providers was not associated with being diagnosed with OUD or opioid overdose in inpatient or observation stays. Conclusions: Recreational and medical marijuana dispensaries were differentially associated with opioid-related hospital stays. Further investigations are warranted to explore the causal pathways of the findings.

Trends in use and misuse of opioids in the Netherlands: a retrospective, multi-source database study

The USA is currently facing a serious opioid misuse epidemic that started with increased prescribing of oxycodone and the inclusion of pain as a fifth vital sign, and eventually resulted in massive overdose mortality. In Europe, including the Netherlands, the medical use of opioids (mainly oxycodone) has also increased since 2009, but an increase in proxies for opioid misuse has not yet been described. For this retrospective, multi-source database study, data were requested from several national databases in the Netherlands to evaluate the following time trends: (1) number of people with opioid prescriptions, (2) number of hospital admissions related to opioid intoxication, (3) number of people treated for opioid use disorder, and (4) number of people who died from opioid poisoning. Data were presented as the number per 100 000 inhabitants, using population data over the years 2008-17 from Statistics Netherlands (Centraal Bureau voor de Statistiek). Data about the number of people with opioid prescriptions was obtained from the Drug Information Project (Genees- en hulpmiddelen Informatie Project) database hosted by the Dutch National Health Care Institute (Zorginstituut Nederland). Data about opioid-related hospital admissions between 2008 and 2017 were obtained from the Dutch National Hospital Care Basic Registration (Landelijke Basisregistratie Ziekenhuiszorg), a database managed by Dutch Hospital Data. Data about addiction treatment were obtained from the National Alcohol and Drugs Information System (Landelijk Alcohol en Drugs Informatie Systeem). Data on opioid mortality between 2008 and 2017 were obtained from the cause-of-death statistics database hosted by Statistics Netherlands. Each database covered almost the entire population of the Netherlands. Between 2008 and 2017, the overall number of prescription opioid users nearly doubled from 4109 per 100 000 inhabitants to 7489 per 100 000 inhabitants, mainly because the number of oxycodone users quadrupled from 574 to 2568 per 100 000 inhabitants. In the same period, the number of opioid-related hospital admissions tripled from 2·5 to 7·8 per 100 000 inhabitants, and between 2008 and 2015 the number of patients in addiction care for opioid use disorders other than heroin increased from 3·1 to 5·6 per 100 000 inhabitants. Opioid-related mortality was stable between 2008 and 2014 with 0·21 deaths per 100 000 inhabitants, but after 2014 it increased to 0·65 per 100 000 inhabitants in 2017. Prescription opioid use increased substantially between 2008 and 2017, and several proxies for misuse show a parallel increasing trend. Although the Netherlands is far from the opioid epidemic faced by the USA, safe opioid prescribing guidelines should be implemented to prevent further escalation and to keep opioid painkillers available for those in need. Radboud University Nijmegen Medical Centre.

Opioid-related hospitalizations in Pennsylvania: A latent class analysis

BackgroundOpioid abuse is associated with substantial morbidity and often results in hospitalization. Despite this, patient-level factors associated with opioid-related hospitalizations are not well understood. MethodsWe used the Pennsylvania Health Care Cost Containment Council dataset (2000–2014) to identify opioid-related hospitalizations using primary and/or secondary ICD-9-CM hospital discharge codes for opioid use disorder (OUD), opioid poisoning, and heroin poisoning. Latent class analyses (LCA) of patient-level factors including sociodemographic characteristics, pregnancy, alcohol, tobacco, other substance use, and psychiatric disorders were used to identify common patterns within hospitalizations. ResultsAmong 28,538,499 hospitalizations, 430,569 (1.5%) were opioid-related. LCA identified five latent class (LC) patient groups associated with opioid-related hospitalizations: pregnant women with OUD (LC1); women over 65 with opioid overdose (LC2); OUD, polysubstance use and co-occurring psychiatric disorders (LC3); patients with opioid overdose without co-occurring polysubstance use (LC4); and African American patients with OUD and co-occurring cocaine use (LC5). LC3 was the largest latent class (58.2%) with annual hospitalizations doubling over time. DiscussionAmong patients with opioid-related discharges, we identified five subpopulations among this sample. These findings suggest increased outpatient OUD treatment, mental health service support for patients with co-occurring psychiatric disorders and polysubstance use to prevent overdose and hospitalization.

Dissociation between the growing opioid demands and drug policy directions among the U.S. older adults with degenerative joint diseases.

We aim to examine temporal trends of orthopedic operations and opioid-related hospital stays among seniors in the nation and states of Oregon and Washington where marijuana legalization was accepted earlier than any others.As aging society advances in the United States (U.S.), orthopedic operations and opioid-related hospital stays among seniors increase in the nation.A serial cross-sectional cohort study using the healthcare cost and utilization project fast stats from 2006 through 2015 measured annual rate per 100,000 populations of orthopedic operations by age groups (45–64 vs 65 and older) as well as annual rate per 100,000 populations of opioid-related hospital stays among 65 and older in the nation, Oregon and Washington states from 2008 through 2017. Orthopedic operations (knee arthroplasty, total or partial hip replacement, spinal fusion or laminectomy) and opioid-related hospital stays were measured. The compound annual growth rate (CAGR) was used to quantify temporal trends of orthopedic operations by age groups as well as opioid-related hospital stays and was tested by Rao–Scott correction of χ2 for categorical variables.The CAGR (4.06%) of orthopedic operations among age 65 and older increased (P < .001) unlike the unchanged rate among age 45 to 64. The CAGRs of opioid-related hospital stays among age 65 and older were upward trends among seniors in general (6.79%) and in Oregon (10.32%) and Washington (15.48%) in particular (all P < .001).Orthopedic operations and opioid-related hospital stays among seniors increased over time in the U.S. Marijuana legalization might have played a role of gateway drug to opioid among seniors.

Opioid-related US hospital discharges by type, 1993–2016

ObjectiveTo classify and compare US nationwide opioid-related hospital inpatient discharges over time by discharge type: 1) opioid use disorder (OUD) diagnosis without opioid overdose, detoxification, or rehabilitation services, 2) opioid overdose, 3) OUD diagnosis or opioid overdose with detoxification services, and 4) OUD diagnosis or opioid overdose with rehabilitation services. MethodsSurvey-weighted national analysis of hospital discharges in the Healthcare Cost and Utilization Project National Inpatient Sample yielded age-adjusted annual rates per 100,000 population. Annual percentage change (APC) in the rate of opioid-related discharges by type during 1993–2016 was assessed. ResultsThe annual rate of hospital discharges documenting OUD without opioid overdose, detoxification, or rehabilitation services quadrupled during 1993–2016, and at an increased rate (8% annually) during 2003–2016. The discharge rate for all types of opioid overdose increased an average 5–9% annually during 1993–2010; discharges for non-heroin overdoses declined 2010–2016 (3–12% annually) while heroin overdose discharges increased sharply (23% annually). The rate of discharges including detoxification services among OUD and overdose patients declined (−4% annually) during 2008–2016 and rehabilitation services (e.g., counselling, pharmacotherapy) among those discharges decreased (−2% annually) during 1993–2016. ConclusionsOver the past two decades, the rate of both OUD diagnoses and opioid overdoses increased substantially in US hospitals while rates of inpatient detoxification and rehabilitation services identified by diagnosis codes declined. It is critical that inpatients diagnosed with OUD or treated for opioid overdose are linked effectively to substance use disorder treatment at discharge.

Opioid medication discontinuation and risk of adverse opioid-related health care events

BackgroundBetween 2012 and 2017, the United States dramatically reduced opioid prescribing rates. While this may be appropriate given the opioid epidemic, there has been little research to guide the clinical practice of discontinuing patients from opioid medications and opioid death rates have continued to increase. ObjectiveTo determine the relationship between time to opioid discontinuation and the risk of an opioid-related emergency department visit or hospitalization among high dose opioid users. DesignWe applied Cox proportional hazard models to 2013–2017 Medicaid claims data to research this relationship. ParticipantsMedicaid beneficiaries in Vermont who filled prescription opioids at high daily doses (at least 120 morphine milligram equivalents) for 90 or more consecutive days and who subsequently discontinued opioid prescriptions (n = 494). Main measuresThe outcome was an opioid-related adverse event defined as an emergency department visit or hospitalization with a primary or secondary diagnosis of opioid poisoning or substance use disorder. Key resultsThe median length of time to discontinuation was 1 day indicating that half of patients had no dose reduction prior to discontinuation. 86% of patients discontinued within 21 days (considered rapid tapering in recent clinical guidelines). 49% of members had an opioid-related hospitalization or emergency department visit. After controlling for sociodemographic and clinical factors, each additional week of discontinuation time was associated with a 7% reduction in the probability of having opioid related adverse event (p < 0.01). Although 60% of members had a diagnosed substance use disorder prior to tapering, <1% of beneficiaries were transitioned onto an opioid use disorder medication. ConclusionsFaster rates of opioid tapering were associated with a greater probability of adverse events and many patients discontinued opioids suddenly, with no dose reduction. Additional clinical guidance, research, and interventions are needed to ensure that patients' opioid prescriptions are discontinued safely.

US National Trends in Opioid-Related Hospitalizations Among Patients With Cancer

This study evaluates the patient demographics and clinical characteristics of 14 095 opioid-related hospitalizations from the US National Inpatient Sample (NIS) of the Healthcare Cost and Utilization Project (HCUP).

EPR19-069: Opioid Use Among Cancer Patients Undergoing Surgery and Their Associated Risk of Re-admissions and Emergency Department Visits in the 1-Year Postsurgical Period

Background: Prescription opioid use and overdose has steadily increased over the past years, resulting in a dramatic increase in opioid-related emergency department (ED) visits and hospitalizations. Methods: This study used a prospective cohort of cancer patients having undergone surgery in Montreal (Quebec) to describe their post-discharge opioid use and identify potential patterns of unplanned health service use (ED visits, hospitalizations). Provincial health administrative claims were used to measure opioid dispensation as well as hospital re-admissions and ED visits. The hospital warehouse, patient chart and patient interview will be used to further describe patient’s medical profile. Marginal structural models will be used to model the association between use of opioids and risk of ED visits and hospitalizations. Inverse probability of treatment and censoring weights will be constructed to properly adjust for confounders that may be unbalanced between the opioid and non–opioid users as well as to account for competing risk due to mortality. Reasons for the re-admissions will also be presented as part of the analyses. Covariates will include patient comorbidities, medication history, and healthcare system characteristics such as nurse-to-patient and attending physician-to-patient ratios. Results (interim): A total of 821 were included in the study; of these, 73% (n=597) were admitted for a cancer procedure. At postoperative discharge, 605 (74%) of patients had at least one opioid dispensation, of which the majority (67%) were oxycodone with hydromorphone being the second most prescribed (28%). Among those who filled a prescription, mean age was 66 (13.4), 68% had no previous history of opioid use, and 10% have had 3 or more dispensing pharmacies in the year prior to admission, compared to less than 1% for the non–opioid users. Overall, 343 people refilled their opioid prescription at least once and 128 at least twice during the 1-year postoperative period. Among cancer patients who were opioid users, 214 ED visits occurred in the 1 year after surgery compared to only 40 for the non-cancer opioid users. Conclusion: This study will help to identify the risk profile of cancer patients who are most likely to continue using opioids for prolonged periods following surgical procedures as well as quantify the impact of opioid use and its associated burden on the healthcare system in order to identify areas for possible interventions.

Prescription Drug Monitoring Programs and Opioid Overdoses: Exploring Sources of Heterogeneity.

Prescription drug monitoring program are designed to reduce harms from prescription opioids; however, little is known about what populations benefit the most from these programs. We investigated how the relation between implementation of online prescription drug monitoring programs and rates of hospitalizations related to prescription opioids and heroin overdose changed over time, and varied across county levels of poverty and unemployment, and levels of medical access to opioids. Ecologic county-level, spatiotemporal study, including 990 counties within 16 states, in 2001-2014. We modeled overdose counts using Bayesian hierarchical Poisson models. We defined medical access to opioids as the county-level rate of hospital discharges for noncancer pain conditions. In 2010-2014, online prescription drug monitoring programs were associated with lower rates of prescription opioid-related hospitalizations (rate ratio 2014 = 0.74; 95% credible interval = 0.69, 0.80). The association between online prescription drug monitoring programs and heroin-related hospitalization was also negative but tended to increase in later years. Counties with lower rates of noncancer pain conditions experienced a lower decrease in prescription opioid overdose and a faster increase in heroin overdoses. No differences were observed across different county levels of poverty and unemployment. Areas with lower levels of noncancer pain conditions experienced the smallest decrease in prescription opioid overdose and the faster increase in heroin overdose following implementation of online prescription drug monitoring programs. Our results are consistent with the hypothesis that prescription drug monitoring programs are most effective in areas where people are likely to access opioids through medical providers.

Naloxone Deserts in NJ Cities: Sociodemographic Factors Which May Impact Retail Pharmacy Naloxone Availability.

Retail pharmacies in NJ are permitted to dispense naloxone without a prescription. However, not all pharmacies have participated in this effort, and it is not clear what factors may impact its availability. We sought to determine the naloxone availability of select NJ cities and what sociodemographic factors are associated with its availability. We compared naloxone availability in retail pharmacies to median household income, population, and the prevalence of opioid-related hospital visits (ORHV). All retail pharmacies in ten New Jersey cities were surveyed by phone in February-July 2017. The standardized survey instrument asked scripted questions to each pharmacist concerning the stocking of naloxone for dispensing. Median household income data and population data for each city were obtained from census.gov . Opioid-related hospital visits were obtained through the NJ SHAD database and the prevalence of ORHV was calculated. Naloxone availability was compared to median household income, population, and ORHV using Spearman's rho and Pearson's correlation. Naloxone availability in the 90 retail pharmacies we surveyed was 31% and ranged from 15.38 to 66.67% by city. An increase in median household income indicated more pharmacy naloxone availability. An increase in population indicated less pharmacy naloxone availability. While no significant relationship existed between ORHV and pharmacy naloxone availability, we did identify individual cities with severe opioid-related public health concerns with limited naloxone access. Naloxone deserts exist in select high-risk New Jersey cities, and pharmacy naloxone availability may be positively related to median household income and negatively related to population.

The association between county-level safety net treatment access and opioid hospitalizations and mortality in New York

BackgroundIncreases in pharmaceutical opioid sales have paralleled the quadrupling of prescription opioid overdose deaths and spikes in emergency department visits for non-medical opioid prescription overdoses. In response, federal and state governments have advanced a myriad of policies to reduce opioid availability and increase treatment access, aimed to ultimately reduce opioid-related mortality. Despite these efforts, including ACA Medicaid expansion and more robust prescription drug monitoring programs, opioid-related mortality has continued to rise in NY and 29 other states. This study examined whether geographic access to Federally Qualified Health Centers, opioid treatment programs, and buprenorphine providers mitigated opioid-related hospital visits (emergency department, inpatient, and all visits) and mortality, by county, between 2012 and 2014. MethodsThe authors examined the relationships among opioid-related health outcomes and geographic access to treatment options using spatial error regression models at the county (n = 62) level in 2012 and 2014. Z-tests further assessed significant differences in access coefficients between 2012 and 2014. ResultsOf the 62 counties in New York State in 2014, 54 (87.1%) showed increased opioid overdose-related emergency department rates (t = 9.125, p < 0.001), and 37 (59.7%) showed mortality rate increases (t = 1.687, p < 0.1), compared to 2012. Regression models demonstrated significant negative relationships between county-level opioid-related mortality rates and geographic access to opioid treatment programs, Federally Qualified Health Centers in both 2012 and 2014 and buprenorphine providers concentration in 2014 while adjusting for county socio-demographics (all p values < 0.05). Access coefficients were not significantly different between 2012 and 2014 (p > 0.05). ConclusionsGreater geographic access to treatment services was protective against opioid-related mortality. Access to opioid treatment may not be sufficient to mitigate opioid-related hospital visits or mortality, but may offset climbing mortality rates in select counties.

Estimating the number of people who inject drugs and syringe coverage in Australia, 2005–2016

BackgroundEffective targeting of harm reduction programs for people who inject drugs (PWID) requires timely and robust estimates of the size of this population. This study estimated the number of people who inject drugs on a regular basis in Australia, calculated syringe coverage per person and the proportion of their injections covered by a sterile needle and syringe. MethodsWe used trends in indicators of injection drug use to extend the 2005 estimate of the population of people who regularly inject drugs from 2005 to 2016. Included indicators were lifetime/recent injection of illicit drugs, drug-related arrests, drug-related seizures, accidental deaths due to opioids, opioid-related hospital admissions/separations and new diagnoses of hepatitis C virus infection among those aged 15–24 years. Syringe distribution and frequency of injection data were used to assess syringe coverage per PWID and the proportion of their injections covered by a sterile syringe. ResultsThe estimated number of people who regularly inject drugs in Australia increased by 7%, from 72,000 in 2005 to 77,270 in 2016. The annual number of syringes distributed per person increased 34%, from 470 syringes in 2005 to 640 syringes in 2016. Syringe coverage per injection first exceeded 100% in Australia in 2013. ConclusionsDespite Australia’s high syringe coverage by international standards, the number of syringes distributed is likely to be only narrowly meeting demand. It is critical that needle syringe programs be provided with sufficient resources to continue their role as the key intervention required to prevent HIV and HCV transmission among PWID.

Evaluation of the fentanyl patch-for-patch program in Ontario, Canada

BackgroundRising use of prescription opioids is a major public health concern associated with increased risk of mortality worldwide. Fentanyl, a synthetic opioid available in patch form, is particularly concerning given its high potency. To curb the misuse and diversion of fentanyl patches, a Patch-for-Patch (P4P) program was implemented in some counties in Ontario between 2012 and 2015. The program requires that patients prescribed fentanyl must return used patches to the pharmacy before receiving more patches. ObjectiveTo evaluate the impact of the P4P program on fentanyl and non-fentanyl dispensing and opioid-related hospitalizations and deaths. MethodsWe conducted a repeated cross-sectional time-series analysis among counties that implemented the P4P program using Ontario administrative claims data. Because intervention dates varied by county due to staggered program initiation, we aligned all intervention months and examined outcome rates in the 5 years preceding and 12 and 24 months following implementation. We explored the monthly rate of prescriptions dispensed for fentanyl and non-fentanyl opioids, opioid toxicity-related hospital and emergency department visits, and opioid-related deaths. We modeled each outcome using an interventional autoregressive integrated moving average (ARIMA) model and tested the impact of the P4P program using a ramp function. ResultsWe analyzed 16 counties that implemented the P4P program and had at least 12 months of follow-up. The introduction of the P4P program was associated with a 30.5% decline in the volume of fentanyl patches dispensed at 24 months (from 1,277–888 patches per 10,000 population; p = 0.04). In contrast, there was no significant change in the rate of non-fentanyl opioid dispensing (p = 0.32), opioid toxicity related hospitalizations and emergency department visits (p = 0.4) or opioid-related deaths (p = 0.96) in the 12 months following implementation of the program. ConclusionsWe found that the implementation of a P4P program in select counties in Ontario was associated with a lower volume of fentanyl patches dispensed by pharmacies, without an increase in use of other opioids. The program had no measurable impact on rates of opioid toxicity-related hospital visits or deaths. Policymakers should consider the use of P4P programs as part of larger opioid strategy.

Readmissions Following Inpatient Treatment for Opioid-Related Conditions

Background: Previous research suggests that relatively few hospitalized patients with opioid-related conditions receive substance use treatment during their inpatient stay. Without treatment, these individuals may be more likely to have subsequent hospitalizations for continued opioid use disorder. Objective: To evaluate the relationship between receipt of inpatient drug detoxification and/or rehabilitation services and subsequent opioid-related readmission. Methods: This study used combined hospital inpatient discharge and emergency department visit data from the Agency for Healthcare Research and Quality’s Healthcare Cost and Utilization Project. Our sample consisted of 329,037 patients from seven states with an opioid-related index hospitalization occurring between March 2010 and September 2013. Multivariate analysis was conducted to examine the relationship between opioid-related readmission and the receipt of inpatient drug detoxification and/or rehabilitation during the index visit. Results: A relatively small percentage (19.4%) of patients with identified opioid-related conditions received treatment for drug use during their hospital inpatient stay. Patients who received drug rehabilitation, but not drug detoxification, during an opioid-related index hospitalization had lower odds of an opioid-related readmission within 90 days of discharge (odds ratio = 0.60, 95% confidence interval = 0.54–0.67) compared with patients with no inpatient drug detoxification or rehabilitation. Conclusions/Importance: A low percentage of patients receive inpatient services for drug use during an index stay involving an opioid-related diagnosis. Our findings indicate that receipt of drug rehabilitation services in acute care hospitals is associated with a lower 90-day readmission rate. Further research is needed to understand factors associated with the receipt of inpatient services and readmissions.